Episodic SOAP Note: Tom Walker|NRP 531,Latest 2022/2023 complete, Already graded A.

Episodic SOAP Note: Tom Walker DOS: 10/14/18 ID: Tom Walker (M) DOB: 1/3/75 (45) CC: Atopic Dermatitis (eczema) Right Knee Injury Subjective HPI: Mr. Tom Walker is a 45-year old is a Caucasian male who appears well groomed and a reliable historian. He presents today with itching has been so bad that it is keeping him awake at night, and his skin has little cracks that bleed. He has been using OCT hydrocortisone cream for flares. His eczema flare in the bend of his arms is (9/10). He loves to take hot showers, but notices he itches more after them. He has had these flareups on occasion in the past. HPI: Tom injured his right knee while playing basketball 4 days ago. He hasn’t been able to bear weight on his knee and is using crutches. He felt a “pop” and had to be carried off the floor. The swelling and bruising are intense. He has been using ice, resting, elevating his knee, and wearing an ace bandage on his knee for support. He reports pain (7/10). He has been taking Tylenol XS. Past Medical Hx: Meniscus Tear 2009 Surgical Hx: Tom had a meniscus repair with a scope on the same knee in 2009. He also had an appendectomy last August. Family Hx: His mother has elevated cholesterol and his brother is obese with high blood pressure. Medications: NKDA OTC hydrocortisone cream, Tylenol® XS Social Hx: He is a non-smoker but reports smoking pot one time in college. He drinks about 4– 6 beers per night. Tom’s mother is an RN in New Jersey Education Level: College Graduate Objective PE: VS: BP - 120/78 P - 70 R - 16 T - 98.2 HT:72’ WT:250# BMI: 33.9. General: He is a well-nourished, well developed male who appears in distress as evidence by being unable to bear weight on his knee and is using crutches. HEENT: Pupils are equal, round, and reactive to light and accommodation CV: Normal S1, S2; no S3, S4 with no murmurs or extra sounds Pulm: Breath sounds clear; no wheezes, rales, or rhonchi noted Abdomen: Bowel sounds active in all quadrants; soft, non-tender to palpation; nondistended. Pt denies differences in vision, double vision, blurry vision; no congestion, no hearing loss; no chest pain, SOB, heart palpitations; no changes in appetite; no changes in mood or memory. Relevant specialty tests: No tests with Atopic Dermatitis Lachman’s test- the patient lays on the table with leg bent at a 30-degree with the foot flat, and if the knee moves freely without reaching a firm point is a tear (Bickley, L. S., Szilagyi, P. G., & Bates, B., 2017). Pivot shift test- the injured leg is extended, and the foot is rotated at the same time as pressure is applied to the outside of the knee as the knee is bent. Instability in the tibia suggests an ACL tear (Hong, E., Kraft M.C., 2014). Right knee x-ray to r/o fracture (Domino, F.J., Baldor R.A., Golding, J., Stephens, M., 2018). 5 Open-Ended Questions Mr. Walker how long have you had Atopic Dermatitis (eczema)? The onset of atopic dermatitis in childhood is most common in patients, and onset after 30 is very uncommon. What treatments have you tried in the past that have made your symptoms better or worse? Patients with atopic dermatitis should not bath more than once daily. Do you have any family history of allergic reactions? Establishes if patient has a family sensitivity to irritants. When do you notice that you flare ups tend to occur? Atopic individuals are sensitive to low humidity and often flare in the winter (Thomsen, S.F., 2014). Have you had a previous knee injury prior to four days ago? Establishes history of previous injury, and potential reinjury. Have you noticed any pain or noises with walking? Locking or catching when walking suggests internal derangement. Snapping may indicate inflammation of the iliotibial band, and pain worsening with bending and walking show issues with patellofemoral joint (Papadakis, M.A., McPhee, S.J., Rabow, M.W. eds., 2019). Identify a minimum of 2 barriers The first potential barrier to quality health care the patient can potentially experience is financial. The cost of treatment can be a drain on Mr. Walker resources as evidence by being unable to bear weight on his knee causing him to have to miss work. The second potential barrier is access to quality health care. Living in rural areas often experience barriers to healthcare that limit their ability to obtain the care they need. Having access to proper care can delay healing. To have enough healthcare access, necessary and appropriate services must be available and obtainable in a timely manner. As an FNP, we should ask patients about the existence of financial barriers and employ strategies to decrease their impact. According to (Domino, F.J., Baldor R.A., Golding, J., Stephens, M., 2018), Family Nurse Practitioners are perceived by patients as pleasant, open, responsive, and approachable to the client’s needs making is more likely for a patient to feel able to discuss any potential barriers. Codes L20.9 Atopic Dermatitis, unspecified M25.561 Pain in right knee E & M CODES 99211 99212 99213 99214 99215 TIME IN MINUTES: 5 10 15 25 40 COMPENENTS REQUIRED 2 OF 3 History PF EPF D C Chief Complaint X Brief HPI X Extended HPI X Problem Pertinent (ROS) X Extended (ROS) Complete (ROS) Pertinent FSH X Complete FSH EXAMINATION PF EPF D C Problem Focused Expanded Problem Focused Detailed X Comprehensive References Bickley, L. S., Szilagyi, P. G., & Bates, B. (2017). Bates' guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins. Domino, F.J., Baldor R.A., Golding, J., Stephens, M. (2018). The 5-Minute Clinical Consult. 26th ed. Wolters Kluwer Health. Hong, E., Kraft M.C. (2014). Evaluating anterior knee pain. Med Clin North Am; 98 (4): 697- 717. Papadakis, M.A., McPhee, S.J., Rabow, M.W. eds. (2019). Current Medical Diagnosis & Treatment New York, NY: McGraw-Hill. Thomsen, S.F. (2014). Atopic dermatitis: natural history, diagnosis, and treatment. ISRN Allergy; 2014:.